jul /11 /16

Congestive Heart FailureManuel Fonseca Crescioni Medical internHospital San Lucas Guayama P.R

✤ IN USA CHF is the MCC of being admitted to the hospital

Heart Failure

✤Dysfunction of the heart as a pump

✤Results in insufficient 02 delivery to tissues acompanied by the accumulation of fluid in the lungs

Pathophysiology

✤ Activation of renin-angiotensin system

✤ Angiotensin II( TPR, Aldosterone)

✤Can be either from systolic dysfunction( decreased EF and heart dilatation) or from diastolic dysfunction ( inability to relax and recieve blood, EF is preserved sometimes even above normal)

Causes of Systolic Heart Failure✤ HTN (MC)

✤ MI

✤ Valvular heart dz of all types

✤ All 3 account for the vast majority of cases (over 95%)

Systolic Heart Failure✤ Less common causes of systolic dysfunction are;

✤ Etoh

✤ Postviral (idiodpathic) myocarditis = Often due to coxsackie B virus

✤ Radiation

✤ Adriamycin(doxorubicin)

✤ Chagas

✤ Hemochromatosis

✤ Thyroid dz

✤ Peripartum cardiomyopathy

✤ Thiamine deficiency

Presentation✤ Dyspnea (SOB)

✤ Orthopnea(worse when lying flat, relieved when sitting up or standing)

✤ Rales , Wheezing on lung examination Bibasilar crakles, decreased breath sounds at the bases due to pleura effusion

✤ JVD

✤ S3, S4

Diagnostic Test

✤ Echocardiography (To distinguish systolic from diastolic dusfunction) every pt must get echo to evaluate EF

✤ Best initial test= Transthoracic echo

✤ Most accurate test= MUGA Scan , Nuclear Ventriculogram,

✤ BNP

Systolic Dysfunction (low EF) Tx.✤ ACE inhibitors , ARB*

✤ B-blockers*

✤ Spirinolactone/eplerenone*

✤ Hydralazine/ nitrates*

✤ Diuretics

✤ Digoxin (does not lower mortality in CHF, controls sx.)

✤ Implantable defibrillator*/ Biventricular pacemaker*( EF below 35%)

✤ Transplantation when all else fails

Distolic Dysfunction (CHF w/ Preserved EF ) Tx.

✤ Nothing we know lowers mortality in diastolic dysfunction

✤ Clearly beneficial= B-Blockers and Diuretics

✤ Clearly not Beneficial Digoxin and Spirinolactone

✤ Uncertain = ACE inhib, ARB’s & hydralazine

References✤ Harrisons Principles of Internal Medicine

15th Eugene Braunwald

✤ Medscape

✤ New York Heart Association

✤ Fundamental of Pathology Husain A. Sattar

✤ Master The Boards Step 2 CK Conrad Fischer, MD